GW1--05223_Well Construction - GW1_20240903

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W_._._e�:L( RECORD
ECORD
This form caul be rued for single or mult��ells" �" For Inca l the ONLY:
_-_ ----
N.Well Contractor Information:
Mitchell Dean Cook .14•WAT. "_ - --
ER�'LONL+ti
,-FROM TO ` Dk:S(:11-ATFN -
Wcll ContractorName• �- _'�_"
ft. rt.
2043 A ...-
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NC Well Connectaq Certification Number 15.ODYER(:ASING. for:^ultiree cd wells)'t)R LINERSIf ap Icable —'•:—..-.-
-FROM_^ TO S IAL. ...._.,..._.-.-
Denms Holland Well Drilling, -• DIAMETER THICKNESS _ MATERIAL.
_. __-,-- _ _.. ._._ r Inc. o t' ft. ia.
,'ft, /
(:omissny Naror. �_ ____ - T 6 ', t
•IC iNNE'RCASING R<TUB ff:•(Rc theruial..close _ T
Z.Well FROM TO DIAMETER MATERIAL
ConstructionPermitN:�. _ ft, ft. Ia.
List all applicable well permits(1.e.County,,Stare, Va.-dance,�'ecrlon,etc..)- -"_-'_-__- TT` --
3,Well Use(check well use): ti ft. Tft. in. -"-�
Water Supply Well: _T FROM :6--'-' DIAMETER LOT SIZE THIC atiS atA'rEliA1.
0Agnculwail l7M(miaipfll/Rtblic ft� ft. in.
ClCieothermal(l.lcntinp/(;Doling Supply) 7 sidenlial Water Supply(single) R'^ ft. -�ft. in._� '-
oIndustrial/i.ommercial ItJ{h!St 'iutial Water Supply(shored) !§•GROUT'�-_' �'_� "" - -
(-Aril:alion . FROM O..._ h1A'rERIA Il.7- 6aI P(.A CFMEeff Mk:1lIpD h AM()UMr
Non-Waist Supply Well: ------•---•----•_._Q fr. ft.
[7Monitrning ^•fl. ft.
pA~7`1P, lf�f/ - �? .s: . . sfe2 P.
Injection Wrll; ^----�—DRecuvery ...._ y rd,62.. .
°Aquifer Recharge °Groundwater Remudiatiun 1:9,,AND/GRAYEL PACK(if:Upticable).. ...
I)AgUlfer Sierage and Recovery (.JSRI1111Iy Barrier ! FROM TO MATERIAL EMPLACEMENT M FTHOU-'
fl. ��ft.
°Aquifer'fest LJStonnwater Drainage - - -- •„_,�_
O L'.XI)erI,ne..iital•[eehiiolo ft. ft.
(ty 0Subsidence Control
UC)e011termAl((sexed 1..00 20:DRILLING LOG{tittpch'additional if aecesi �.•
P) LiTraeet'' FROM TO DF4CRIPTIOnc lot,harda.as,solUreeek ripe,train du,nr
hJGeothennal ltieating/Cooling Monti_ DOther(explain under H2I Remarks) ft. ft.
4, Date Well(s)Completed; r. 0 '-J 1,�kVell IDH /V ^AT - _ _ _ _ ._.-_____,
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ft. ^ft.
So.Well Location: — — _ _ _. .._.._..._.
ft. ft.
Facility/Uwnct awe Facility lDN(ifapplicablc) --..•...-._.__......__.. _._..._._._.-......_.. ...-.....__.____._..._._ .---.____.......: ..:.:._
• ft. n. _) Z$2
Physical Address,City,and lip __ —_ fs;
....__
��k21.REMARKS � I ::;74;u_' _ ..,, —•_,_- .
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Comity Parcel Identification No.(PIN) —`-�--- - - -- '� ---..-----'•_.-_-_____..
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: T��_ __ �_�.. —_
Orwell field,one laVtong is sufficient)
356 )/.. (,' m o ... f--5/ w -Ad i 't' :A.e:/./_._, -..(e,..._ eeif_--. 1.9"7,i3 -2v-a-_r
Signature of Certified Well Contractor .. Date
b.Is(are)the wcll(s): petmaocnt or C7Tcmporaty
fly signing this form,I hereby certify that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7. Is this a repair to an existing well: DYes or Imo- copy of this record lists been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nawe of the
repuir under li2I remarkssection or on the hack of this form. 23.Site diagram or additional well details:
You may use the hack o1'this page to provide additional well site details or well
A.Number of wells constructed:_�_ _ ___ construction details. You may also attach additional pages if necessary.
For multiple in/ertion or nun•svnter supply wells ONLY with the sane caatrucdnn,you can
submit one form. SUILIV TTA1,INS'I'UCTIONS
9.Total well depth•helow land surface: .30A. ' __ _ ,_,,,(rt.) 24a. �'QL-,All Wells: Submit this form within 30 days of completion of well
Fat multiple wells his all depths if different(example-3 200'and 2©/00') construction to the;following:
10.Static water level below top of casing:. ar0 '
__�____(ft.) Division of Water Resources,Information Processing Unit,//rvarrlevel irabnvecasing,use . 1617 Mail Service.Center,Raleigh,NC 27699-1617
11.Borehole diameter:6____ (in.) 24b. Frlr In tenon Wells ONLY: Inaddition to sending the form to the address in
Rotary 241a above, also submit a copy of this Ibnn within 30 days of completion of well12.Well construction method; ry _._.,..__..__-___._ consrction to the tbllowing:
(i.c.auger,missy,cable,direct push,etc.)
__ Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: �~ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) ,ys Air lift 24e•For Water Supply&Injection Wells:
Method of test:__,_.___--._,__- Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:,H &H Amount:,12„oz• well construction to the county health department of the county where
.........___. ..:,.._......-.._.....--- -- constructed.
Recited Aunusl gal J
Farm(iW-I Notlh Carolina Department of Environment and Natural Resources••Division of Water Resources

(;;;Otecs:
1830 Lakeside Dr
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Macon County Franklin,NC 28734
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/ u ablic Health (828)349—2490
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WELL CONSTRUCTION AUTHORIZATION
Owner Jeffry Epperson WEL 071324-1 SEP N/A
Location 344 Middle Skeenah Road, Franklin PID 6582342897 ACREAGE 8.3
Directions_ South Georgia Road, R Addington Bridge Road, R Middle Skeenah Road, L onto driveway just past Volunteer Fire Station
Desi•n Shared Well Permit T •e New Construction Expiration Valid for 60 Months
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40'
Proposed Well Area 120'x40' 46•
40'
30' 120' ;-1m
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42' �. House 3
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Diagram not to scale
Permit Conditions
1) Well shall be constructed in compliance with all 15A NCAC 2C rules.
2) Maintain all minimum setbacks, were applicable.
3) When well and pump are completed, contact MCPH for inspection.
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The issuance of this permit by MCPH in no way guarantees the issuance of other permits.The property owner is responsible for checking with appropriate governing
bodies in meeting their requirements.This permit is subject to revocation if the site plan,plat,site,or intended use changes.All rules in 15A NCAC 02C Well Construction
Standards are incorporated by reference into this document,including any subsequent amendments to those rules,and shall be adhered to.Please contact MCPH for
inspection when well head and pump installation are completed and you are ready to place well into service.
Any person abandoning a well must submit to MCPH Form GW-30 upon completion.
July 30, 2024 // kis , I_11k' ,-_.
Issue Date Anna Hokrein, REHSi 3384